Original Article Int J Clin Prev Dent 2015;11(4):261-264ㆍhttp://dx.doi.org/10.15236/ijcpd.2015.11.4.

261
ISSN (Print) 1738-8546ㆍISSN (Online) 2287-6197

Oral Hygiene Status and Cognitive Function in Indonesian

Elderly
Linda Soetanto Kusdhany1,2, Tri Budi Rahardjo1, Dinni Agustin1, Chaidar Masulili2,
2 3
Sri Lelyati , Eef Hogervorst
1
Center for Ageing Studies, Universitas Indonesia, 2Department of Prosthodontics, Faculty of Dentistry, Universitas Indonesia,
3
Jakarta, Indonesia, Department of Human Sciences, Loughborough University, Loughborough, United Kingdom

Objective: The aim of this study was to determine the relationship oral hygiene status with the decline of cognitive function,
and also considered other factors such as age, gender and education level. The benefits of this study is to improve quality of
life of older person through an increase in oral health.
Methods: Design of this study was cross-sectional, With 224 elderly subjects taken purposively from elderly in posbindu
Citengah Sumedang and south Jakarta. Assessment of cognitive function was done using the mini-mental state examination
(MMSE) developed by Folstein and has been validated. MMSE assessment conducted by interviewing subject and by
observation. Cut off point used for MMSE score is 24. Oral health examination was done using oral hygiene index (OHIS)
with cutoff point 2.9. Statistical Analysis was done using univariate analysis to see the data distribution of observed variables,
bivariate analysis to assess the relationship observed variables with cognitive function of elderly and multivariate analysis to
determine variables that most contribute to the cognitive function of elderly.
Results: The result showed that 74.8% of subjects with MMSE scores above 25 have OHIS value below 3, it indicates that
the better the cognitive function of the subject, in line with improvements of the subject’s oral hygiene. Multivariate analysis
showed that level of education,age and OHIS have association with MMSE scores (p≤0.05).
Conclusion: Level of education, age and OHIS have association with level of cognitive function.

Keywords: oral hygiene, cognition, dementia, aged

Introduction
Dementia is a clinical syndrome characterized by cognitive
and memory impairment such as memory loss and decrease in
Corresponding author Linda Soetanto Kusdhany
intellectual function that cause changes in behavior. Dementia
Department of Prosthodontics, Faculty of Dentistry,
is also defined as a syndrome of progressive decline in in-
Universitas Indonesia, no 4 Jakarta 10430, Indonesia. Tel:
tellectual ability that causes deterioration of cognitive and func-
+62-21-3151216, Fax: +62-21-3151216, E-mail:
tional, thus causing a hindrance in social, work and daily
lindakusdhany@yahoo.com
activities. Symptoms are wide ranging and include loss of mem-
Received November 7, 2015, Revised December 6, 2015,
ory, mood changes, communication difficulties, personality
Accepted December 21, 2015
and behavioural changes in later stages of dementia there will

Copyright ⓒ 2015. Korean Academy of Preventive Dentistry. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
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International Journal of Clinical Preventive Dentistry

be increasing dependency on others for all daily activities [1]. of seven parts:temporal orientation, spatial orientation, learn-
There are several types of dementia, memory and language ing calculation, short term memory, communication and con-
problems are typical in Alzheimer’s disease, whereas in vas- structive apraxia. This tool showed high sensitivity and specif-
cular dementia, cognitive function are more severely deterio- icity [5]. Oral health examination was done using oral hygiene
rated and changes in mood and personality occur in the early index (OHIS) with cutoff point 2.9. This index was calculated
stages and are more severe than in Alzheimer disease. A typical using 6 surfaces examined from 4 posterior and 2 anterior teeth.
clinical finding in Lewy body dementia is a fluctuation in cogni- To obtain the score, each of the six selected tooth surfaces are
tive function and behavioural symptoms [2]. examined for debris and calculus with 0 to 3 criteria and the
Dementia is more common in older age groups. Currently in worst score possible is 6. Total score of Calculus and debris is
Indonesia 17 million people (8%) are over 60 years old. This from 0 to 6 and score more than 3 classified as poor oral hygiene
age group is estimated to grow to 13.5% of the population by [6].
2025. With the lowest calculated 4% prevalence, we estimated Other data such as age, gender and education level were col-
that Indonesia would have 1.4 million cases with dementia over lected through questionnaire. Statistical analysis was done us-
the age of 60 years by 2025 [3]. It is thought to be related to oral ing univariate analysis to see the data distribution of observed
health because of the ability of the elderly to maintain oral hy- variables, bivariate analysis to assess the relationship observed
giene are also reduced. Reduced oral hygiene will trigger a vari- variables with cognitive function of elderly and multivariate
ety of oral and dental problems that will eventually affect the analysis to determine the variables that most contribute to the
masticatory function and nutritional intake. Poor oral health is cognitive function of elderly.
often associated with lower economic income, and physical dis-
abilities condition [4]. Results
The purpose of this study was to determine the relationship
oral hygiene status with the decline of cognitive function, and All subjects in this study had already filled in the inform con-
also considered other factors such as age, gender, and education sent form, and the ethical commission from Faculty of
level. The benefits of this study is to improve quality of life of Dentistry, University of Indonesia had approved the study.
older person through an increase in oral dental health. Distribution of several variables observed can be seen in Table
1. From this Table 1, we could see that the average subjects were
Materials and Methods young old population (<70 years old). Average subjects had fair
oral hygiene and normal cognitive function.
Design of this study was cross-sectional, With 224 elderly Table 2 showed the result of bivariate analysis of cognitive
subjects taken purposively from elderly in posbindu Citengah
Sumedang and South Jakarta. Assessment of cognitive function
was done using the mini-mental state examination (MMSE) de- Table 2. Relationship of cognitive function (MMSE Score) and several
observed variables
veloped by Folstein and has been validated. MMSE assessment
conducted by interviewing subject and by observation. Cut off MMSE
Variable p-value
point used for MMSE score is 24 [5]. MMSE score was used ＜24 a
25-30b
to evaluate cognitive functions with two categories, MMSE
OHIS
score between 14 and 24 will be classified as decline cognitive Good (0.00-2.9) 41 (59.4) 116 (74.8) 0.02*
function/dementia. Score MMSE greater than 24 were consid- Poor (3.00-6.00) 28 (40.6) 39 (25.2)
ered normal. The maximum MMSE score is 30 and it consists Age (yr)
＜70 52 (55.9) 60 (32.6) 0.00*
≥70 41 (44.1) 124 (67.4)
Education
Table 1. Distribution of obeserved variables Elementary 60 (64.5) 57 (31.0)
Middle to high education 33 (35.5) 127 (69.0) 0.00*
Mean±standard Range
Variable Sex
deviation (minimum-maximum)
Men 32 (34.4) 49 (26.6)
Age (yr) 68.23±7.17 52-98 Women 61 (65.6) 135 (73.4) 0.18
OHIS 2.33±1.63 0-6
Values are presented as number (%). MMSE: mini-mental state exami-
MMSE score 25.26±4.89 4-30 a b
nation, OHIS: oral hygiene index. Dementia; Normal. *Analysis
OHIS: oral hygiene index, MMSE: mini-mental state examination. using chi-square test, significant with p＜0.05.

262 Vol. 11, No. 4, December 2015

 Linda Soetanto Kusdhany, et al：Oral Hygiene Status and Cognitive Function in Indonesian Elderly
Figure 1. Relationship of cognitive function and oral hygiene.
OHIS: oral hygiene index.
Figure 2. Relationship of cognitive function and education level.
function (MMSE score) and several observed variables. It can
be sumarized that oral hygiene,age and education have a sig-
nificant relationship with cognitive function (MMSE score).
Only Sex didn’t have a significant relationship with cognitive
function (MMSE score).
The Figure 1 showed that proportion of bad oral hygiene was
higher in subjects with dementia/decline cognitive function
(40.6%) compare to 25.2% in normal subjects.
The proportion of education level in subjects with dementia
and without dementia could be seen in Figure 2. 64.5% of sub-
jects with dementia, got elementary level of education.
Final multivariate analysis using numeric data of MMSE as
dependent variables was done and the result was showed in
Table 3.
The result of multivariate analysis showed that education
level, age and oral hygiene were risk factors of decreased cogni-
tive function.
Table 3. Final model of multivariate analysis
Variable  p-value
Constant 18.25 0.00
OHIS −1.29 0.04*
Age 1.97 0.001*
Education level 3.57 0.00*
OHIS: oral hygiene index. *Analysis using multiple linear regression,
significant with p＜0.05.
Discussion
Both rural comunity (Citengah, Sumedang) and urban com-
munity (South Jakarta) were chosen as location of study in order
to have an overall description about number of subjects with de-
mentia in Indonesia. In this study we use MMSE to measure cog-
nitive function because it is a simple and also reliable method
and subjects didnt have to be physically examined.
Dentists and researhers included in this study were already
trained and calibrated before the data collection to measure in-
dices in this study. Two trained dentists with minimum of 5 years
experience as dentist included in this study to measure OHIS
and two researchers with highly experienced in epidemio-
logical surveys were trained to use MMSE.
The simplified OHIS was chosen to measure oral hygiene be-
cause it offers a more rapid method for evaluation of oral cleanli-
ness of population groups. It is the simple method to use in a
survey [6]. MMSE developed by Folstein. This instrument was
used to give general condition about cognitive aspect, atention,
orientation, language, memory and recall. Age, education and
ethnicity give dominant impact to the measurement, that is the
reason that we use the MMSE modification so it can be used for
subjects with low level of education. MMSE modification has
already undergone validation and reliability test with cronbach
alpha 0.87 [7]. MMSE is widely used as instrument to asess cog-
nitive impairment but is limited in distinguish different types
of dementia. It is also less usefull in detecting early or mild cog-
nitive changes [8].
Our result showed that education level,age and oral hygiene
related with decline of cognitive function. This result similar
with the study in Finland [2] and also similar to the result of study
in USA [9]. In our study 40.6% subjects with dementia have
poor oral hygiene compare to the study in Finland 60% subjects
with vascular dementia have poor oral hygiene. Wu et al. [9] in
his study showed that lower cognitive function was strongly as-
sociated with increase in numbers of missing teeth and increase
percentage of periodontal disease.
Educational level also showed an association with cognitive
function, this result is identical to that several previous study
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International Journal of Clinical Preventive Dentistry
[10]. Final multivariate analysis in this study showed that gen-
der has no association with cognitive function. This result is also
similar with the study of El Zoghbi et al. [10]. However a differ-
ent result was found in the age variable. In our study we found
an association between age and cognitive function but not in the
result of study from El Zoghbi et al. [10]. Different result was
found in age. In our study we found an association between age
and cognitive function but not in the result of study from El
Zoghbi et al. [10]. This differences maybe due to differences
in age group. On average, the subjects in our study were at a
younger age than in the study of El Zoghbi et al. [10]. The cutoff
point for age group in our study is 70 years comparedto the cut
off point 80 years in the study of El Zoghbi et al. [10]. Our study
using more younger age cut off point so that the differences be-
tween age group more distinct.
Furuta et al. [11] in his study concluded that a potential causal
pathway were oral health status affected swallowing ,dysphagia
and cognitive impairment and finally malnutrition. Oral health
status as measured by indicators such as number of teeth and
denture wearing gave direct impact on swallowing function.
Wearing denture and keeping the stable mandibular position
and stable occlusion were important for swallowing function.
Loss of occlusion may disturb coordination of swallowing
function.
Miranda Lde et al. [12] found in her study a significant associ-
ation between cognitive decline and age,marital status and us-
ing denture. In this study, no statistically significant association
was found between cognitive impairment, gender and educa-
tion level. Altough several other studies found a significant as-
sociation between level of education and cognitive impairment.
The same result was obtained in our study. These contradicting
result maybe due to majority of subjects had low education
(elementary level of education).
Limitation of our study is that we were not taking notice about
using denture due to limitation of subjects using denture.
Further study is needed to assess association of using denture
and cognitive function. Planning a clinical trial comparing im-
pact of denture treatment in subjects with and without dementia
should be done. Many factors should also be considered in doing
study about using denture and cognitive function, such as osteo-
porosis and other systemic diseases which can affect denture
treatment [13,14].
Conclusion
Level of education, age and OHIS have association with level
264 Vol. 11, No. 4, December 2015
of cognitive function.
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